Citation Nr: 0010980
Decision Date: 04/26/00 Archive Date: 05/04/00
DOCKET NO. 96-47 075 ) DATE
)
)
On appeal from the
Department of Veterans Affairs (VA) Regional Office (RO) in
Buffalo, New York
THE ISSUE
Entitlement to service connection for an acquired psychiatric
disorder, variously diagnosed.
REPRESENTATION
Appellant represented by: New York Division of Veterans'
Affairs
ATTORNEY FOR THE BOARD
J. Horrigan, Counsel
INTRODUCTION
The veteran had active service from November 2, to December
16, 1994.
This matter comes before the Board of Veterans' Appeals
(Board) on appeal from an October 1995 rating decision by the
RO which denied service connection for a psychiatric
disorder. In his Substantive Appeal (VA Form 9) dated in
October 1995, the veteran indicated that he wished to appear
at a hearing before a member of the Board at the RO. The
requested hearing was scheduled in August 1997, but the
veteran failed to appear. The case is now before the Board
for appellate consideration at this time.
FINDING OF FACT
The veteran has an acquired psychiatric disorder, variously
diagnosed, which had its onset during service.
CONCLUSION OF LAW
An acquired psychiatric disorder, variously diagnosed, was
incurred in service. 38 U.S.C.A. §§ 1131, 5107(a) (West 1991
& Supp. 1999); 38 C.F.R. § 3.303 (d) (1999).
REASONS AND BASES FOR FINDING AND CONCLUSION
I. Factual Background
The Board notes initially that it finds that the veteran's
claim for entitlement to service connection for a psychiatric
disorder to be "well grounded" within the meaning of
38 U.S.C.A. § 5107(a), in that the claim is plausible. All
relevant facts pertaining to this claim have been developed
to the extent possible, and no further assistance to the
veteran is required to satisfy the VA's duty to assist him in
the development of this claim as mandated by 38 U.S.C.A.
§ 5107(a).
On the veteran's March 1994 examination prior to service
entrance, he was evaluated as psychiatrically normal. Review
of the service medical records reveals that the veteran was
referred to the mental health clinic of a military hospital
by his unit commander in mid November 1994. There is no
clinical record that the psychiatric evaluation called for by
the unit commander took place, or, if it did take place, what
the clinical findings consisted of. The veteran was not
afforded a physical examination prior to discharge from the
service. An option form contained among the service medical
records indicates that the veteran exercised an option not to
have a service discharge examination.
Following service, several attempts were made by the RO to
obtain additional service medical records, but no additional
service medical records were obtained.
On a VA examination of the veteran's feet in March 1995 it
was said that the veteran was separated from service after
six weeks and had been told that it was for mental reasons
and because of pain in his right foot. The examiner said
that the veteran was very "combative" in his conversation
and complained that he had been told that he was "mentally
sick" and that his foot pain was of no consequence. It was
said that his attitude toward the Army was "very
belligerent".
During a further VA general medical examination in April 1995
it was noted that the veteran had had a recent altercation
with his girlfriend and strangled his cat. It was said that
he had only served in the military for six weeks because of
altercations with drill sergeant, improper use of his weapon
on the rifle range, and threatening another soldier. It was
said that his affect was somewhat labile with obvious anger
at times, and much suppressed anger. The examiner assessed
the veteran as having an obvious adjustment disorder,
possibly with either a character disorder or post-traumatic
stress disorder (PTSD). The examiner said that the veteran
needed a full psychiatric evaluation and should be considered
fairly unstable.
On VA psychiatric examination in September 1995 the veteran
was said to have had problems on the rifle range during
service and had been threatened by his sergeant. He felt
that he had been ridiculed and humiliated during service. He
was said to have a lot of emotional pain. The veteran was
said to suffer from dyslexia and had trouble learning
instructions, which were a source of his difficulties in the
service. The veteran said that he had flashbacks of basic
training while under stress on a couple of occasions. On
evaluation the veteran was dishelved and displayed anger and
despondency. Feelings of hopelessness and helplessness were
reported. He was described as obviously frightened but there
was no thought disorder. Hallucinations and delusions were
denied but he did admit to suicidal ideation. Insight and
judgment were poor. The diagnosis on Axis I was dysthymic
disorder, rule out PTSD. A personality disorder, not
otherwise specified was diagnosed on Axis II. On Axis IV the
stressors were said to be service experiences and the threats
the veteran received while in the service. The examiner
noted that the veteran's psychological testing revealed
indications consistent with severe clinical depression and
his profile was that of an acutely disturbed man.
VA clinical records reflect outpatient treatment during 1996
for psychiatric symptomatology. During an initial evaluation
in March 1996 he reported impaired sleep, nightmares, mood
swings, and irritability. He reported that during the
service he had been threatened with a pistol and choked by
his sergeant. He had also been humiliated in front of many
other trainees. He said that he met with a psychologist and
was then discharged from service. The assessments were the
same as those reported after the September 1995 VA
psychiatric examination. After VA psychological evaluation
in May 1997, the impression was mood disorder, not otherwise
specified, with atypical depression, irritability, anxiety
and impulsive features.
On a VA psychological examination in September 1999, the
veteran gave a history of being threatened with a pistol and
being choked during service. He also said he was accused
unjustly of threatening a sergeant. He also reported heavy
drug and alcohol abuse after service. He gave a history of a
VA hospitalization in January and February 1999 following a
suicide attempt. After evaluation, the diagnosis on Axis I
was depressive disorder, not otherwise specified. A
personality disorder, not otherwise specified was diagnosed
on Axis II. The evaluating psychologist was not convinced
that the veteran had PTSD, since it was not certain that the
veteran had the full range of symptoms or that his stressors
were true. The examiner concluded that the veteran did not
have psychological symptoms due to service.
In a July 1999 statement, the Director of U.S Armed Forces
Center for Research of Unit Records indicated that there was
no documentation of the veteran being attacked by other
soldiers while in the military.
II. Analysis
Service connection may be granted for disability due to
disease or injury incurred in or aggravated by peacetime
service. 38 U.S.C.A. § 1131. Service connection may be
granted for disability initially diagnosed after service when
all the evidence indicates that the disability had its onset
during service. 38 C.F.R. § 3.303(d). A personality
disorder is a developmental abnormality and not disability
for which service connection may be granted. 38
C.F.R.§ 3.303(c). Service connection for PTSD requires
medical evidence establishing a clear diagnosis of the
condition, credible supporting evidence that the claimed in
service stressor actually occurred, and a link, established
by medical evidence, between current symptomatology and the
claimed in service stressor. 38 C.F.R.§ 3.304(f).
Initially, the Board notes that the records indicate that the
veteran's post service psychiatric diagnoses have included a
personality disorder. A personality disorder is a
development abnormality and not a disease or injury for which
service connection may be granted. 38 C.F.R.§ 3.303(c). The
record also indicates that the possibility of a diagnosis of
PTSD has been considered during the veteran's VA treatment
and examinations in recent years. However, a definite
diagnosis of PTSD has never been rendered in the veteran's
case. Moreover, entitlement to service connection for PTSD
also requires credible supporting evidence that the stressor
claimed as resulting in PTSD be established by credible
supporting evidence. The stressor reported by the veteran
during his 1996 VA hospitalization, and on other occasions,
was, essentially, assaults perpetrated by a sergeant during
basic training. Since the veteran's claim for service
connection for PTSD is clearly not related to combat, his own
statements are insufficient to establish an inservice
stressor; rather the stressor must be corroborated by service
records or by other credible evidence. Doran v. Brown, 6
Vet. App. 283 (1994); Zarycki v. Brown, 6 Vet. App. 91
(1993).
Review of the veteran's service medical records discloses no
evidence that the veteran was the victim of any assault
and/or battery in service, and there is otherwise no
corroborating evidence that the reported assaults/batteries
actually occurred. Therefore the in service stressor upon
which the veteran's claim for service connection for PTSD is
based has not been verified. Since there is no definite
diagnosis of PTSD and since the veteran's reported stressors
have not been verified, service connection for PTSD is not
warranted.
However, the veteran has reported that he was evaluated by a
psychologist during service and then discharged, in part,
because of psychiatric symptoms. The service medical records
do show a referral to a mental health facility during the
veteran's brief period of service, which is indicative of the
fact that his unit commander thought he was in need of a
psychiatric consultation. Moreover, the veteran was
clinically noted to have psychiatric symptomatology in March
and April 1995, just a few months after service discharge.
Additionally, he was diagnosed as having an dysthymic
disorder on a VA psychiatric examination in September 1995,
less than a year after service, and the examining physician
on that occasion clearly attributed the veteran's psychiatric
symptoms to service. A mood disorder was diagnosed after a
VA psychological assessment in May 1997 and a depressive
disorder was diagnosed after a VA psychological examination
in September 1999. All of these diagnoses constitute
acquired psychiatric disorders for which service connection
may be granted. While the veteran was also diagnosed as
having a personality disorder, such a disorder may coexist
with an acquired psychiatric disability such as a dysthymic
disorder, a depressive disorder, or a mood disorder. The
Board further notes that the VA psychologist who examined the
veteran in September 1999 did not believe that his
psychiatric symptoms were attributable to service. However,
that examiner did not have access to the veteran's clinical
records. Considering the apparent need for a psychiatric
consultation in service, and clinical documentation of
acquired psychiatric pathology soon after service, and the
one medical opinion linking a current acquired psychiatric
disorder to service, the Board is of the opinion that the
preponderance of the evidence indicates that the veteran
developed an acquired psychiatric disorder in service, and
service connection for this disability is therefore
warranted.
ORDER
Service connection for an acquired psychiatric disorder is
granted.
BRUCE E. HYMAN
Member, Board of Veterans' Appeals
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